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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600539
Report Date: 09/28/2022
Date Signed: 09/28/2022 12:43:05 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/26/2022 and conducted by Evaluator Mary G Flores
COMPLAINT CONTROL NUMBER: 28-AS-20220926160438
FACILITY NAME:PICO RIVERA GARDENSFACILITY NUMBER:
198600539
ADMINISTRATOR:MEIR SHAUL YITZI TEICHMANFACILITY TYPE:
735
ADDRESS:6525 ROSEMEAD BLVD.TELEPHONE:
(562) 949-8489
CITY:PICO RIVERASTATE: CAZIP CODE:
90660
CAPACITY:185CENSUS: 173DATE:
09/28/2022
UNANNOUNCEDTIME BEGAN:
09:39 AM
MET WITH:Yitzi Teichman - AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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9
Client's room has mold
Client's room has roaches
INVESTIGATION FINDINGS:
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Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation(s). LPA Flores met with Yitzi Teichman Administrator and explained the reason for the visit.

The visit consisted of the following: LPA Flores requested copies of client/staff roster. LPA conducted a tour of the facility with Yitzi Teichman and observed client room's randomly chosen; room#3,#4,#5,#30,#31,#32,#34, #35,#40,#42. LPA interviewed clients #1(C1),#2(C2),#3(C3),#4(C4),#5(C5),#6(C6),#7(C7),#8(C8),#9(C9),#10(C10), and staff #1(S1),#2(S2),#3(S3),#4(S4).

The investigation revealed the following: Regarding allegation: Resident's room has mold. It is alleged there is black mold on client's walls. Interviews with clients revealed 7 out of 10 residents interview stated to not have mold or observed mold in the rooms. 2 out of 10 clients interview stated to have/had mold in the room and 1 out of 10 clients refused to be interview. (CONTINUED LIC (9099C)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 28-AS-20220926160438
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PICO RIVERA GARDENS
FACILITY NUMBER: 198600539
VISIT DATE: 09/28/2022
NARRATIVE
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Interviews with staff revealed, 2 out of 4 staff interview have not observed or have clients report mold in client's rooms. 1 out of 4 staff interview stated to know one room has mold and will be repair within the next two days. 1 out of 4 staff stated a room had mold but has recently been painted and no longer has mold. During the tour of the facility LPA Flores observed mold in room #4's bathroom ceiling.

Based on interviews, observation, and documents review conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Regarding allegation: Client' has roaches. It is alleged client has roaches in the room. Interviews with clients revealed, 4 out of 10 clients interview stated to have or observed roaches in the last three months. 3 out of 10 clients stated there are no roaches or have not observed roaches at the facility. 2 out of 10 clients stated that sometimes there are roaches at the facility or rooms. 1 out of 10 clients refused to be interview. Interviews with staff revealed 2 out of 4 staff stated there are roaches in some of the rooms of those clients that keep food in the room and 2 out of 4 staff stated the facility is under a pest control plan. During the tour of the facility LPA observed live and dead roaches in room #4. Documents reviewed revealed facility receives services twice a month.

Based on interviews, observation, and documents review conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Tittle 22, Division 6 and Chapter 1 are being cited.

Exit interview was conducted with Yitzi Teichman Administrator and a copy of this report, LIC 9099D, and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/26/2022 and conducted by Evaluator Mary G Flores
COMPLAINT CONTROL NUMBER: 28-AS-20220926160438

FACILITY NAME:PICO RIVERA GARDENSFACILITY NUMBER:
198600539
ADMINISTRATOR:MEIR SHAUL YITZI TEICHMANFACILITY TYPE:
735
ADDRESS:6525 ROSEMEAD BLVD.TELEPHONE:
(562) 949-8489
CITY:PICO RIVERASTATE: CAZIP CODE:
90660
CAPACITY:185CENSUS: 173DATE:
09/28/2022
UNANNOUNCEDTIME BEGAN:
09:39 AM
MET WITH:Yitzi Teichman - AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
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5
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9
Client's fan is broken
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
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12
13
Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation(s). LPA Flores met with Yitzi Teichman Administrator and explained the reason for the visit.

The visit consisted of the following: LPA Flores requested copies of client/staff roster. LPA conducted a tour of the facility with Yitzi Teichman and observed client room's randomly chosen; room#3,#4,#5,#30,#31,#32,#34, #35,#40,#42. LPA interviewed clients #1(C1),#2(C2),#3(C3),#4(C4),#5(C5),#6(C6),#7(C7),#8(C8),#9(C9),#10(C10), and staff #1(S1),#2(S2),#3(S3),#4(S4).

The investigation consisted of the following: Regarding allegation: Client's fan is broken. It is alleged client's fan is broken again. Interviews with clients revealed 7 out of 10 clients interview stated air conditioning (A/C) is working and it maintains a good temperature. 2 out of 10 clients stated that the A/C is not that great and 1 out of 10 clients refused to be interview. (CONTINUED ON LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20220926160438
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PICO RIVERA GARDENS
FACILITY NUMBER: 198600539
VISIT DATE: 09/28/2022
NARRATIVE
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Interviews with staff revealed 2 out of 4 staff stated the A/C works throughout the facility. 1 out of 4 staff stated the A/C works in some area and not in others and 1 out of 4 staff stated the A/C was recently fixed in one of the rooms. During tour of the facility LPA observed the facility has central air conditioning throughout the facility and the temperature was not too hot or too cold. LPA Flores observed room #4 had a fan plug and working during the visit. A/C thermostats were observed between 72-74 degrees F., located by the rooms observed. Document review revealed on 7/7/22 air compressor was replaced and on 9/9/22 services were provided.

Based on interviews, observation, and document review conducted, there was insufficient evidence to prove the allegation(s). Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Exit interview was conducted with Yitzi Teichman Administrator and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20220926160438
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PICO RIVERA GARDENS
FACILITY NUMBER: 198600539
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/12/2022
Section Cited
CCR
80087(a)
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80087 Building and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.



This requirement is not met as evidence by:
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Administrator is to ensure facility is maintain in sanitary and in good repair at all times, will repair room #4's bathroom to remove mold and will submit pictures to the department and will by POC due date 10/12/22
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Based on observation licensee did not ensure room #4's bathroom is free of mold which poses a potential risk to the health, safety, or personal right of the persons in care.
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Type B
10/12/2022
Section Cited
CCR
80087(a)(1)
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80087 Building and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (1) The licensee shall take measures to keep the facility free of flies and other insects.

This requirement is not met as evidence by:
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Administrator is to ensure facility is maintain free of cockroaches at all times, will contact pest control services and create a plan that will eliminate roaches in room #4 and submit new plan to the department by POC due date 10/12/22.
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Based on observation licensee did not ensure room #4 is free of roaches which poses a potential risk to the health, safety, or personal rights of the persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5